Растяжение большой грудной мышцы у пожилых: лечение без операции

Slideshow - Figure. Photograph of patient showing sunken chest and muscle. An 80-year-old man presents with left anterior chest wall pain and swelling that began after a fall 5 days earlier. The patient fell on uneven ground during a walk, landing awkwardly on his outstretched left arm. Since the injury, he has noticed bruising extending from the upper chest into the axilla and proximal upper arm. The patient is right-hand-dominant and describes difficulty pushing himself up from a chair and mild weakness when attempting to reach across his body. He denies numbness, tingling, or neck pain. On physical examination, there is extensive ecchymosis involving the left anterior chest wall, axilla, and proximal medial arm. Mild swelling is present over the left pectoral region. Palpation elicits tenderness along the anterior chest wall near the axillary fold. Compared with the contralateral side, there is subtle asymmetry of the anterior axillary contour. Active shoulder range of motion is preserved, although resisted adduction and internal rotation reproduce pain and reveal mild weakness. Neurovascular examination of the extremity is normal. A picture of the patient’s chest deformity and swelling is shown in the Figure. Plain radiographs of the shoulder and chest reveal no acute fracture. Pectoralis major tears are uncommon injuries that most frequently occur in younger male athletes during eccentric loading activities such as bench pressing. However, these injuries can also occur in elderly patients following relatively low-energy trauma, including falls or forceful arm... Submit your diagnosis to see full explanation. Pectoralis major tears are uncommon injuries that most frequently occur in younger male athletes during eccentric loading activities such as bench pressing. However, these injuries can also occur in elderly patients following relatively low-energy trauma, including falls or forceful arm movements.1,2 The pectoralis major is a large chest muscle composed of clavicular and sternocostal heads that converge into a broad tendon inserting on the lateral lip of the bicipital groove of the humerus. The tendon is susceptible to rupture when excessive force is applied during shoulder abduction and external rotation or following a traumatic fall.1,2 Patients typically present with acute chest or shoulder pain, swelling, ecchymosis extending into the axilla and upper arm, and weakness with shoulder adduction and internal rotation. Physical examination may reveal loss of the normal anterior axillary fold contour, chest wall asymmetry, and tenderness along the pectoralis major tendon.1,2 In the acute setting, a large hematoma can obscure the diagnosis, making recognition more challenging. MRI remains the imaging modality of choice because it accurately identifies the location and extent of tendon injury and assists with treatment planning. However, an MRI is often not performed in elderly patients who elect for nonoperative treatment.1,2 Management depends largely on patient age, functional demands, and tear severity. In young patients with complete tendon ruptures, surgical repair is generally recommended because it provides superior restoration of strength, cosmesis, and functional outcomes compared with nonoperative treatment. In contrast, elderly patients are often treated conservatively with analgesics, ice, sling immobilization, and progressive physical therapy. Studies of elderly patients (average age of 86 years) demonstrated that despite significant ecchymosis and blood loss associated with these injuries, most returned to their baseline level of function within several months without surgical intervention. Because many elderly individuals have lower functional demands and substantial medical comorbidities, the risks of surgery frequently outweigh the benefits.1,2 Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistant. References 1. Magone K, Ben-Ari E, Gyftopoulos S, Virk M. Pectoralis major tendon tear: a critical analysis review. JBJS Rev. 2021;9(8). doi: 10.2106/JBJS.RVW.20.00224 2. Beloosesky Y, Grinblat J, Weiss A, Rosenberg PH, Weisbort M, Hendel D. Pectoralis major rupture in elderly patients: a clinical study of 13 patients. Clin Orthop Relat Res. 2003;(413):164-169. doi:10.1097/01.blo.0000076803.53006.12